Keith on Gender Affirmations
Summer 2019
One of the first plastic surgery cases in which Jonathan Keith (MD ’06, Res ’13) scrubbed in as a med student was a male-to-female vaginoplasty. “I’d never seen anything like it,” he says. “It was transformative and powerful. And it all stemmed from, what I felt to be, the imagination and creativity of one man.”
Training under J. William Futrell, former professor and chair of plastic surgery at Pitt, Keith became inspired to care for transgender patients. Futrell was the only surgeon performing gender-affirming surgeries in Pittsburgh at the time, and Keith saw that his practice improved people’s outlook.
After the vaginoplasty, Keith says, “I saw how much the surgery affected the patient’s life, and how she really changed.”
The rates of suicide attempts are alarmingly high among transgender people—46 percent of trans men in this country and 41 percent of trans women, according to the American Foundation for Suicide Prevention. Keith wants clinicians to “open their eyes to the reality of the situation.” People are dying because of how they feel in their own bodies.
In 2018, Keith became the first plastic surgeon in New Jersey to perform a female-to-male phalloplasty. But the road getting there was a rocky one. The taboo of gender-reassignment surgery was an ever-present barrier in Keith’s training. It would take several twists of fate and chance encounters with people from Pitt, actually, that would get him to finally establish a transgender-centered practice.
The first obstacle was Futrell’s retirement, which occurred while Keith was still in med school. “When the only person with the expertise retires [from an institution], the progress just kind of goes away,” he says.
Keith buried the idea of serving the trans community for years until later in his residency, when a fellowship led him to Ghent University Hospital in Belgium. There, Keith met Stan Monstrey—who had studied under Futrell decades earlier.
“Monstrey ran a highly productive and respected gender-affirming surgery program out of the hospital where I was learning microsurgery,” says Keith. Monstrey was then, and still is, traveling the world, training others on gender-confirmation surgery.
This opportunity reinvigorated Keith’s interest, he says. “The surgery was creative and dovetailed with the things that I like to do, which is very large, complex multidisciplinary surgery.” Gender-affirming surgery requires a team of specialists from plastic surgery, urology, gynecology, and anesthesiology. Outside the operating room, internal medicine docs, psychologists, infectious disease experts, and other specialists get involved.
In 2014, the U.S. Department of Health and Human Services reclassified gender-affirming surgery, changing it from experimental to a proven therapy. Medicare started covering it, and Medicaid and private insurance companies followed suit.
That’s when the pent-up demand became apparent, says Keith, who had already performed scores of feminizing or masculinizing “top surgeries” for trans patients. “Patients started talking to each other and funneling very organically by word-of-mouth into my office,” he says.
Despite the uptick in demand, three years passed before Keith was ready to perform “bottom surgery.”
“Basically it took from 2015, when I first started seeing patients, until 2018 to have all the pieces [and players] in place . . . to design the surgery itself and to know that I was able to do it safely,” says Keith. “That’s when we started.”
He performed his first phalloplasty in February 2018 and his first vaginoplasty in May of the same year. After taking months to monitor his patients for major post-op complications and seeing none, Keith felt comfortable continuing with the program. Beginning in November 2018, Keith had one gender-affirming surgery scheduled biweekly through spring 2019.
As assistant professor at Rutgers New Jersey Medical School and codirector of Rutgers Center for Transgender Health, Keith’s guiding principle working with trans patients is respect. That, he says, means “really delving deep into what they want.”
Keith recalls Futrell’s bravery decades earlier, when reassignment surgery hovered on the fringe of plastic surgery.
In the spirit of Futrell’s commitment to the trans community, Pittsburgh will once again become a hub for people wishing to transition. Pitt and UPMC are planning a transgender health care center in the Three Rivers region.
BY ERIN HARE
For a third of women, the badges of childbirth and long life come at an unexpected and embarrassing cost—pelvic organ prolapse. That’s a condition where the bladder, uterus, or rectum bulge into the vagina, or even outside the body. More than 10 percent of American women find it bothersome enough to undergo surgical correction.
One version of the surgery involves inserting polymer mesh materials through an incision in the vagina to hoist the pelvic organs back into place; but in April, concerns about safety and efficacy led the Food and Drug Administration to stop the sale of mesh for this purpose.
Still, the clinical need remains, says Pamela Moalli (Res ’98, Fel ’00). She’s an MD/PhD professor of obstetrics, gynecology, and reproductive sciences at Pitt and a pelvic reconstructive surgeon at UPMC Magee-Womens Hospital.
Together with Steven Abramowitch, PhD associate professor of bioengineering at Pitt, Moalli has spent the past decade working to create a better mesh. Recently, the pair secured a $2.5 million National Institutes of Health grant for the continuation of this work.
The problem with currently available mesh materials, Moalli says, is that they weren’t designed to be used in the vagina. They’re repurposed from hernia surgery, and most are made of knitted polypropylene. The materials sometimes deform and wrinkle under the vertical strain of the pelvic organs, which might cause pain and erosion. Polypropylene is also quite stiff, which can cause the tissue to thin over time.
Moalli and Abramowitch created softer 3D-printed mesh, designed to hold its shape while also holding the pelvic organs up. They hope their new materials will make pelvic organ prolapse surgery safer and more effective for the hundreds of thousands of women who need it.
“Issues that negatively impact quality of life and are specific to women often do not get the attention that they deserve in research,” Moalli says. “This is an opportunity to develop solutions for women that are designed based on an understanding of the uniqueness of female anatomy and biology.” —Erin Hare
OBITUARIES
Charles A. Coltman Jr.
Nov. 1, 1930–Nov. 28, 2018
Charles Coltman Jr. (MD ’56) liked to close meetings with a quip: “Everyone opposed to adjourning, please remain seated,” recalls biostatistician John Crowley of his former boss.
Coltman, who died in November 2018, enjoyed a prolific career as a physician and cancer researcher.
Well known for his precise, military bearing, garnered through a 20-year career in the U.S. Air Force, Coltman also possessed a softer, more humorous side.
Crowley, now chief of strategic alliances with the nonprofit Cancer Research and Biostatistics, worked under Coltman during his tenure as chair of SWOG (formerly the Southwest Oncology Group). Even today, Crowley’s speech is littered with “Coltmanisms,” like referring to the latest cancer-drug combo as “alphabetagooferdust” or “difungomuctane.”
“He commanded respect just by his presence, but his leadership was much more than that,” Crowley says. “He really knew the field and commanded respect with his knowledge.”
Guiding SWOG from 1981 to 2005, Coltman championed randomized clinical trials, technological innovations, and the use of statistics. Coltman also cofounded the San Antonio Breast Cancer conference, today the premier international conference on breast cancer, and forged enduring relationships between American and Japanese cancer researchers. As a researcher, he investigated renal, gastrointestinal, and lung cancers, as well as therapies for lymphoma. He co-led the study that established the chemotherapy regimen known as CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) as the standard of care for patients with advanced-stage, aggressive lymphoma.
“He made you want to do your best for him,” Crowley says. —Adam Reger
Anthony Miller Harrison
Dec. 6, 1938–Jan. 28, 2019
When Department of Surgery chair Timothy Billiar (Fel ’90, Res ’92) was a resident, he and his peers called attending surgeon Anthony Harrison (Res ’65) “the best intern on the service.” Harrison, whose intern year was long behind him by then, earned the admiring nickname because, Billiar says, “He’d come in before the interns, who are supposed to be the first ones in the hospital, and he’d have already seen patients and written notes.”
Harrison, who served as professor of surgery at the University of Pittsburgh beginning in 1992, died in January. Before joining the faculty, Harrison in 1970 helped found General Surgical Associates, which grew into one of the region’s largest surgical practices.
His patient-centered approach included checking on patients multiple times a day and sharing his home phone number.
In an era of increasing specialization, Harrison’s ability to handle just about any surgical procedure set him apart.
“In the same morning, he might operate on a pancreas, do a vascular surgery, and perform a thyroidectomy,” says Distinguished Professor of Surgery Andrew Peitzman (Res ’84), who also trained under Harrison.
“If someone came in with an unusual condition, and you asked, ‘Have you ever seen this before?’ Tony’s answer was always, ‘Yes, I’ve done it multiple times,’” says Brian Zuckerbraun (Res ’05), chief of the Division of General Surgery.
The department is working with Harrison’s family to establish the Anthony M. Harrison Chair of Surgery in his memory. For information, contact Gary Dubin at dgary@pmhsf.org or 412-647-9113. —AR
Michael L. Hess
Aug. 10, 1942–April 13, 2019
When Michael Hess (MD ’68, Res ’71) taught medical students about heart failure, he would throw the class a football and a beach ball. The props, says his longtime colleague Maureen Flattery, an NP, helped demonstrate the difference between a nondilated heart (football) and one that is diseased and dilated (beach ball). “His cardiac physiology lectures were famous.”
Hess, a widely published authority on cardiovascular physiology and the medical management of cardiac transplantation, as well as the recipient of seven outstanding teacher awards from Virginia Commonwealth University (VCU), died in April.
In the mid ’70s, heart transplant cases were considered strictly surgical; Hess saw a need for more comprehensive care. One Friday in the hospital, he introduced himself to pioneering heart-transplant surgeon Richard Lower. By the following Monday, Lower’s post-op patients were in Hess’s care.
Hess was named professor of medicine in cardiology in 1980 and went on to garner many more leadership roles at VCU: He led the heart failure transplant program, the Division of Cardiology, the Division of Cardiology’s laboratories and research, and the advanced heart failure program. In 2013, Hess established the university’s cardio-oncology program, which he directed until he retired in 2018.
In 1981, claiming he had “no one to talk to,” Hess cofounded the International Society for Heart and Lung Transplantation, of which he served as the first president. ISHLT, which remains the world’s leading society of transplant physicians and surgeons, operates the International Registry for Heart and Lung Transplantation. —Kristin Bundy
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